Prevalence of Self-Medication Practice and Associated Factors among Pregnant Women Who Attended Antenatal Care at Public Hospitals of North Shewa Zone, Amhara Region, Ethiopia

Background Self-medication practice is the use of medicine without consulting health professionals to treat self-recognized illness by the general population including pregnant women. Inappropriate self-medication practice during pregnancy may pose harmful consequences for the fetus as well as the mother. There is not given much attention on the practice of self-medication among pregnant women in our setting. Therefore, this study aimed to assess the prevalence of self-medication practice and associated factors among pregnant women who attended antenatal care at North Shewa Zone public hospitals. Methods An institution-based cross-sectional study was conducted from June 01, 2022 to July 30, 2022, among 650 pregnant women who attended antenatal care at North Shewa Zone public hospitals. A multistage sampling technique was employed. The questionnaires were pretested. A structured interviewer-administered questionnaire and reviewed medical records were used for data collection. Epi-data version 4.6.2 and SPSS version 20 were utilized for data entry and analysis, respectively. Bivariate and multivariable logistic regression was done to identify associated factors, and P values less than 0.05 were considered statistically significant. Results The prevalence of self-medication practice among pregnant women was 65.38%. Housewives (AOR = 0.097 95% CI 0.030, 0.310), farmers (AOR = 0.117, 95% CI 0.028, 0.493), people with health insurance (AOR = 0.507, 95% CI 0.300, 0.858), and people in preconception care (AOR = 0.038, 95% CI 0.011–0.135) were less likely to practice self-medication, while people with primary education (AOR = 3.00, 95% CI 1.217, 7.435), income less than 3,000 birr (AOR = 5.46, 95% CI 1.41, 21.1), participants in the first (AOR = 4.183, 95% CI 2.12, 8.24) and second trimesters (AOR = 2.05, 95% CI 1.18, 3.56), pregnant women who lived in rural areas (AOR = 1.579, 95% CI 1.103–2.260), and people who previously practiced self-medication (AOR = 8.2, 95% CI 5.04, 13.3) were more likely to practice self-medication. Conclusion From the present finding, it can be concluded that self-medication among pregnant women is high. Previous self-medication practice, gestation period, educational status, monthly income, no preconception care, no health insurance, being a housewife, farmer, and place of residence were significantly associated with self-medication practice. Therefore, preventive measures such as proper counseling during dispensing, awareness creation programs on preconception care, and enrolling in health insurance programs to minimize the practice of self-medication are necessary.

Background.Self-medication practice is the use of medicine without consulting health professionals to treat self-recognized illness by the general population including pregnant women.Inappropriate self-medication practice during pregnancy may pose harmful consequences for the fetus as well as the mother.Tere is not given much attention on the practice of self-medication among pregnant women in our setting.Terefore, this study aimed to assess the prevalence of self-medication practice and associated factors among pregnant women who attended antenatal care at North Shewa Zone public hospitals.Methods.An institution-based cross-sectional study was conducted from June 01, 2022 to July 30, 2022, among 650 pregnant women who attended antenatal care at North Shewa Zone public hospitals.A multistage sampling technique was employed.Te questionnaires were pretested.A structured interviewer-administered questionnaire and reviewed medical records were used for data collection.Epi-data version 4.6.2 and SPSS version 20 were utilized for data entry and analysis, respectively.Bivariate and multivariable logistic regression was done to identify associated factors, and P values less than 0.05 were considered statistically signifcant.Results.Te prevalence of self-medication practice among pregnant women was 65.38%.Housewives (AOR = 0.097 95% CI 0.030, 0.310), farmers (AOR = 0.117, 95% CI 0.028, 0.493), people with health insurance (AOR = 0.507, 95% CI 0.300, 0.858), and people in preconception care (AOR = 0.038, 95% CI 0.011-0.135)were less likely to practice self-medication, while people with primary education (AOR = 3.00, 95% CI 1.217, 7.435), income less than 3,000 birr (AOR = 5.46, 95% CI 1.41, 21.1), participants in the frst (AOR = 4.183, 95% CI 2.12, 8.24) and second trimesters (AOR = 2.05, 95% CI 1.18, 3.56), pregnant women who lived in rural areas (AOR = 1.579, 95% CI 1.103-2.260),and people who previously practiced self-medication (AOR = 8.2, 95% CI 5.04, 13.3) were more likely to practice self-medication.Conclusion.From the present fnding, it can be concluded that self-medication among pregnant women is high.Previous self-medication practice, gestation period, educational status, monthly income, no preconception care, no health insurance, being a housewife, farmer, and place of residence were signifcantly associated with selfmedication practice.Terefore, preventive measures such as proper counseling during dispensing, awareness creation programs on preconception care, and enrolling in health insurance programs to minimize the practice of self-medication are necessary.

Background
Self-medication is described as the selection and use of medicines, herbs, or home remedies based on an individual's own interests without a health professional's prescription to treat self-recognized illnesses and symptoms [1].Inappropriate self-medication practice during pregnancy results in potential adverse efects on the fetus and increases the chance of drug resistance to the mother, treatment failure, misuse of medication, wastage of resources, and drug dependence [2].Self-medication practice, however, may reduce health costs and save time spent waiting to see doctors for minor illnesses [3].
Self-medication practice (SMP) is currently a global problem [4].Self-medication practice throughout pregnancy has been increasing in several regions of the world, particularly in developing countries [5,6].A study done by Shaikh showed that about 78% of drugs in developing countries were purchased without a prescription [7].Despite the increment of self-medication among pregnant women all over the world, the majority are unaware of the consequences of self-medication [8].
In Ethiopia, self-medication during pregnancy is becoming more prevalent, and the reported prevalence ranges from 15.5% to 70% [9].
Diferent factors are implicated in self-medication practices.Tese include low socioeconomic status, prior experience with medications, use of drugs recommended by relatives, minor illness, lack of access to health services, uncontrolled distribution of drugs, patients' attitudes toward health care providers, long waiting times, drug costs, level of education, age, easy access to drugs without prescription, patient satisfaction, and beliefs about drugs and diseases [2,[10][11][12][13][14].
Rampant practice of self-medication during pregnancy may pose teratogenic and other harmful consequences to the fetus and mother, such as birth defects, miscarriage, allergic diseases, low birth weight, premature birth, developmental disorders, and fetal toxicity.It is estimated that about 10% of birth defects are caused by drug exposure in pregnant women [15].Te risk is higher when the drugs are used during the frst trimester of pregnancy [16].Self-medication can also worsen a patient's health and delay seeking medical advice from a health care provider [17].
Medicines used during pregnancy are usually based on an assessment of their harm to the mother and fetus.In most cases, the frst choice of treatment for conditions during pregnancy is diferent from treatment for women who are not pregnant.Terefore, the choice of drug should be based on pregnancy risk categories which indicate the potential of a drug to cause birth defects if used during pregnancy [18].
Pregnancy-related drugs and medications have the potential to cross the placenta and afect the fetus.A variety of outcomes are possible, such as low birth weight, premature birth, miscarriage, stillbirth, and baby withdrawal after medications [19].
Worldwide, the practice of self-medication with overthe-counter (OTC) drugs among individuals is common.In countries like Ethiopia, even prescription drugs have been dispensed at a very high rate without a prescription which further increases risk of self-medication among pregnant women [20].
In addition to conventional self-medication practice, pregnant women may not realize that social drug use can afect the health of the fetus.About 3.6% of congenital anomalies are caused by substance use during pregnancy [21].Regardless of the introduction of many maternal health care policy programs in Ethiopia such as free antenatal care and reduction exemption policy under the national health insurance system, antenatal visits for rural women are underutilized and have low attention on the risk of selfmedication during pregnancy without prescription.Visits to antenatal care are declining due to low levels of education, lack of access to the media, distance from health centers, and unplanned pregnancies.Hence, this group favors selfmedication and search for alternative medicine [22].
Many pregnant women have little awareness of the harmful impact of self-medication practice in Ethiopia, and there is no health policy to restrict self-medication practice during pregnancy in the country [15].Even though some studies were conducted regarding self-medication practices among pregnant women in Ethiopia, still further studies are needed to get adequate data about the geographical area and population diversity of the country.Te results of this study will serve as an input for the formulation of strategies or guidelines, and policies by program designers and policymakers to mitigate the potential risks of self-medication and its related interventions in antenatal care Terefore, the present study was carried out to show the prevalence of selfmedication and associated factors among pregnant women in North Shewa Zone, Amhara region, Ethiopia 2022.Midda Weremo Hospital (MWH).Among these, six were selected using a simple random sampling method.Te selected hospitals are Debre Berhan Compressive Specialized Hospital (DBCSH), Enat Hospital (EH), Mehal Meda Hospital (MMH), Arerti Hospital (AH), Ataye Primary Hospital (APH), and Shewarobit Hospital (SH).Te sample was proportionally allocated for each hospital, and the allocation was done based on previous 2 months' turnout for antenatal follow-up, which was 3014.Te study participants were selected by the systematic random sampling technique.Te sample interval value (k th ) was 4, and the frst participants were selected randomly by the lottery method from 1 to sample interval.

Method
Te proportional allocation sampling technique was performed by (nf × n)/N (sample fnal * number of total pregnant women attending antenatal care in each hospital/ number of total pregnant women attending antenatal care within the previous 2 months) (Figure 1).

Operational Defnitions and Defnition of Terms
Self-medication practice: It is described as the use of medications (conventional or herbal) for self-identifed illnesses or disorders without a prescription; it also includes the continuous use of medications for recurrent symptoms without a medical professional's order, either by buying them from an unauthorized body or sharing from other person [25].Over-the-counter medicine: It refers to medicine that you can buy without a prescription.Emergency use: It is required to meet the immediate needs of respondents.
Preconception care: It is a set of interventions that are to be provided before pregnancy [26].Better knowledge: One should know the dose, indication, contraindication, and side efect of the drug.

Data Collection Procedure.
A structured intervieweradministered questionnaire was prepared in English after a thorough literature review of previously validated published studies, and it contains fve parts, namely, sociodemographic characteristics, obstetrics factors, conventional medicine practice, herbal medicine practice, and knowledgerelated factors.Te questionnaire was evaluated by an expert in the feld.Ten, the questionnaire was translated into Amharic language and translated back into English language to minimize translation errors.Finally, the Amharic version of a structured interviewer-administered questionnaire was applied to collect the data, such as sociodemographic characteristics, conventional medicine practice, herbal medicine practice, and knowledge-related factors, and reviewed patient medical records were used to extract the necessary obstetrics information.Six BSc midwives and six supervisors contributed to data collection.Te supervisors gave the required information on issues of privacy, confdentiality, and consent seeking before the interview and starting with reviewing medical records.When collecting data, the data collectors used captured pictures of the drugs to easily remember what drugs were used.

Data Quality Assurance.
In order to maintain the quality of the data, data collectors and supervisors received a oneday training session in data collection procedures.Before actual data collection time, the questionnaire was pretested on 5% (32) of the sample size at Deneba Hospital, and then possible adjustment or modifcation was made to the tool.Te reliability of the knowledge section of the questionnaire was checked using Cronbach's alpha test, and the result was 70.Moreover, questionnaires were cross-checked daily for completeness, accuracy, and consistency immediately after data collection.

Data Analysis.
Te collected data were cleaned, coded, and entered into Epi-Data version 4.6.2 and then exported to SPSS version 20 for analysis.A multicollinearity test was carried out between the independent variable using variance infation factors (VIF), and none was collinear (VIF: 1.02-2.5).Descriptive analysis was used to summarize the sociodemographic characteristics of respondents.Te binary logistic regression model was performed for dichotomous variables.Bivariable logistic regression analysis was used to select candidate variables for multivariable logistic regression analysis.Variables with P value <0.25, in bivariable logistic regression, were entered into a multivariable logistic regression model to identify their independent association with the dependent variable.Te regression model ftness was tested by Hosmer and Lemshow goodness test (Model 1 Advances in Pharmacological and Pharmaceutical Sciences Sig. � 0.722, Model 2 Sig.� 0.143, and Model 3 Sig.� 0.943).Finally, results were presented using tables, graphs, fgures, text, and charts.Te strength of the association was reported as adjusted odds ratios, and statistical signifcance was set at p < 0.05 for all analyses.

Ethical Consideration. Ethical approval and clearance
were obtained from Debre Berhan University, Asrat Woldeyes Health Sciences Campus Ethics Review Board with protocol number IRB-055 (Ref.No: IRB58/09/2014 EC).At all levels, ofcials were contacted and asked for permission.Te purpose of the study was explained to the study participants, confdentiality was assured, and verbal consent was obtained before data collection.

Sociodemographic Characteristics.
A total of 650 pregnant women were recruited in this study with a response rate of 97.89%.More than one-third (32.3%) of the women was in the age group of 25-29 years.Te mean age of the participants was 28.81 with a standard deviation of 5.8.Tree hundred and forty-one (52.5%) mothers were living in rural areas.About two-thirds of the participants was Orthodox Christian by religion (65.7%).Most of the participants (88.8%) were attending primary school and above (88.8%),and married (84.1%).Two hundred and sixty-two (40.3%) pregnant women were housewives.Te majority of respondents' (74.1%) income level was below 3,000 ETB.Half of them (50.6%) had valid health insurance to access free point of care from accredited health facilities (Table 1).

Obstetrics Characteristics of the Participants.
More than half (54.2%) of the participants were in the second trimester.Te majority of the pregnant women (74.4%) had a history of pregnancy, with 49.8% having two pregnancies.Seventysix (16%) of them experienced stillbirth.Most of the participants (91.9%) had a history of previous ANC follow-up, and 14.3% of them reported previous pregnancy complications.Te majority (82.9%) of pregnant women gave birth in governmental institutions (Table 2).  4
Te most common source of conventional medicine was private and community pharmacies (26%), followed by friends (10.8%) and pregnant women themselves (8.3%).

Factors Associated with Self-Medication Practice during
Pregnancy.A bivariate logistic regression analysis result showed that preconception care and previous selfmedication on conventional and herbal medicine were factors with self-medication practice, whereas place of residence, distance from health facility, monthly income,  6).
Occupational status, monthly income, health insurance, preconception care, and previous self-medication were signifcantly associated factors with self-medication practice on conventional medicine.Educational status, gestational age, and gravidity were also considered for multivariable logistic regression analysis.Accordingly, occupational status, primary education, lower monthly income (<3,000 birrs), preconception care, frst and second trimester pregnancy, health insurance, and previous self-medication practice were the signifcant associated factors with self-  7).In the present fnding, housewives (AOR � 0.097 95% CI 0.030, 0.310) and farmer pregnant women (AOR � 0.117, 95% CI 0.028, 0.493) were less likely to practice self-medication on conventional medicine compared to those who were employed and students.Likewise, pregnant women with preconception care (AOR � 0.038, 95% CI 0.011-0.135)and health insurance (AOR � 0.507, 95% CI 0.300, 0.858) were less likely to practice self-medication as compared to those without preconception care and health insurance.On the other hand, participants with primary education (AOR � 3.00, 95% CI 1.217, 7.435), pregnant women with income less than 3,000 birr (AOR � 5.46, 95% CI 1.41, 21.1), participants in the frst (AOR � 4.183, 95% CI 2.12, 8.24) and second trimesters (AOR � 2.05, 95% CI 1.18, 3.56), and participants with previous self-medication practice (AOR � 8.2, 95% CI 5.04, 13.3) were with high odds of practicing self-medication during their current pregnancy (Table 7).Occupational status, educational status, residence, gestational age, and distance from the health facility were associated signifcantly with self-medication practice on herbal  Advances in Pharmacological and Pharmaceutical Sciences  8 Advances in Pharmacological and Pharmaceutical Sciences medicine during pregnancy in bivariate logistic regression analysis, and gravidity and monthly income were considered for multiple logistic regression analysis (Table 8).
Pregnant women who lived in rural areas (AOR � 1.94, 95% CI 1.34-2.80)and those who previously practiced selfmedication (AOR � 9.76, 95% CI 6.73,14.16)were 1.94 and 9.76 times more likely to practice self-medication on herbal medicine as compared to those who lived in urban areas and who had not previously practiced self-medication (Table 8).
Te fndings of this study revealed that occupational status was signifcantly associated with self-medication practice.Tis study is supported by studies conducted in Mwanza Tanzania, Ghana, and Nekemte Ethiopia [33,40,41].Pregnant women who were housewives 91% and farmers 88.3% were less likely to practice self-medication than pregnant women who were employed and students.Due to the expansion of medical information, constraints, and media exposure to pharmaceutical promotion, both employed individuals and students have risk to practice self-medication than housewives and farmers [42].
Based on this, the educational status of pregnant women with primary education was signifcantly associated with self-medication.Tis is similar to a study conducted in Bahir Dar, Ethiopia, Jasika Ghana, and Lira Uganda [10,43,44].Te odds of self-medication practice among women whose educational level is primary school were 3.0 times the odds of those with diploma or degree.One explanation for the factors could be that women in diploma or degree programs are more aware of the risks associated with the drug used during pregnancy than those with primary-level education.So, at the diploma or degree level, there is less drug use without a prescription during pregnancy [45].
Participants who had low monthly income (<3,000 birrs) were 5.46 times more likely to use self-medication compared to those who had high monthly income (>6,000 birrs).Te current result is consistent with studies done in Harar Ethiopia, Bahir Dar Ethiopia, Iran, Goba Ethiopia, and Bukavu Eastern DR Congo [2,10,11,13,14].It might be justifed that low-income pregnant women may not be able to aford medical facilities and consult licensed medical professionals.Terefore, they might be urged to purchase cheaper drugs from over-the-counter centers without a prescription, which in turn leads to high-level selfmedication practices.
Pregnant women who had valid health insurance were 49.3% less likely to practice self-medication than those who had no valid health insurance.Tis study is congruent with studies in Northern Ghana (40) and Tigray Ethiopia [46].Valid health insurance helps to pay for health care services, and it can help cover services ranging from routine health care visits to major medical costs for a serious illness.As a result, pregnant women are more likely to follow their prescription because their insurance will pay for both their appointment and their medication.Terefore, health providers help pregnant mothers to enroll for health insurance.
Pregnant women who had preconception care were nearly 53-77.4% less likely to utilize self-medication as compared to those who had not had preconception care before pregnancy, because pregnant women might take advice before conception or early in pregnancy to maximize the health outcome of pregnancy.Health professionals create awareness on the harmful efect of self-medication without prescription.
Te fnding of this study revealed that the frst and second trimesters of gestational age were signifcantly associated with self-medication practice.Tis is similar to a study conducted in Addis Ababa Ethiopia, Northern Jordan, and Ibadan Nigeria [47][48][49].Te odds of selfmedication practice among women in their frst and second trimesters of pregnancy were 4.18 and 2.05 times the odds of those in their third trimester of pregnancy.Because women often have greater symptoms and discomfort during the frst trimester of pregnancy, they frequently need to take their medications.However, this is the more critical time concerning fetal damage associated with drug use.Terefore, more emphasis should be given to the use of medication in the frst and second trimesters of pregnancy [50].
A previous history of self-medication was 5.11-8.2times more likely to lead to self-medication as compared to not having previous experience of the same.Tese factors are similar to the study fndings in Addis Ababa Ethiopia and Lira Uganda [43,48].A possible explanation for this might be that pregnant women would have used self-medicine before they became aware of disease and treatment options, which encourages them to utilize self-medication rather than an alternative course of action.
Pregnant women who lived in rural areas and had previously practiced self-medication with herbal medicine were 1.94 times and 9.76 times more likely to practice selfmedication on herbal medicine as compared to those who lived in the urban area and who had not practiced selfmedication previously.Tese factors are similar to studies in Mwanza, Tanzania [35].A possible justifcation might be that pregnant women who lived in a rural community have low access to antenatal care counseling about the risk of herbal medicine and are familiar with herbal medicine to treat minor illnesses [51].

Conclusion and Recommendation
According to the study's fndings, self-medication by pregnant women is found to be high.It is a huge problem and has to be reduced or prevented with the use of efcient measures and interventions.Factors like having no valid health insurance, no preconception care, low monthly income, primary school educational status, and previous experience of self-medication practice were the predictors of self-medication practice on conventional medicine.Place of residence and previous self-medication with herbal medicine were the factors associated with selfmedication with herbal medicine during their current pregnancy.Te high magnitude and the associated factors require great attention, especially for pregnant women.Considerable attention should be given to increasing pregnant women's access to maternal care services by enrolling them in valid health insurance, lowering the cost of maternal care services, avoiding the provision of medications without a medical prescription, creating a culture using the public media to prevent selfmedication, and creating awareness about preconception care.Finally, the health professionals educating the general population and enhancing pregnant women's awareness about the potential risks of selfmedication during pregnancy at the antenatal care level are crucial.Moreover, the health provider should emphasize more on the implementation of preconception care and national health insurance to reduce the risk of self-medication without prescription during pregnancy.
Advances in Pharmacological and Pharmaceutical Sciences 5.1.Limitation.Te limitations of this study be recall bias which possibly underestimates self-medication practice.Tis study is quantitative; it would be preferable if a qualitative method was used to analyze study subjects' perspectives toward self-medication.

Figure 1 :
Figure1: Schematic presentation of the sampling procedure for self-medication practice and its associated factors among pregnant women who attended antenatal care at public hospitals of North Shewa Zone, Amhara, Ethiopia, 2022.

Figure 2 :
Figure 2: Indications of pregnant women who practice self-medication during pregnancy on conventional medicine at North Shewa Zone public hospitals, October 2022.
Practice during Pregnancy.About 65.38% of the pregnant women practiced self-medication.Of those who practiced self-medication, 30% (95% CL 26.5, 33.4) used conventional medicine and 45.2% (95% CI 41.2, 49) used herbal medicine, while 9.9% of pregnant women used both conventional and herbal medicines during their current pregnancy.A total of two hundred one and two

Table 1 :
Sociodemographic characteristics of pregnant women who attended antenatal care at North Shewa Zone public hospitals, October 2022.
23)and herbal medicine (AOR � 6.15, 95% CL 4.01, 9.43) were more likely to practice self-medication than who had not practiced self-medication previously.Pregnant women with preconception care (AOR � 0.47, 95% CL 0.30, 0.75) were less likely to practice self-medication than those without preconception care (Table

Table 2 :
Obstetric characteristics of pregnant women who attended antenatal care at North Shewa Zone public hospitals, October 2022.

Table 3 :
.Frequency distribution of self-medication practice before and during pregnancy on conventional and herbal medicine at North Shewa Zone public hospitals, October 2022.

Table 4 :
Drugs commonly practiced at each trimester of pregnancy.

Table 5 :
Types of herbal medicine and source of information about herbal medicine for pregnant women who practice self-medication during their pregnancy.

Table 6 :
Model-1.Bivariate and multivariable logistic regression analyses of variables' signifcant association with self-medication practice during pregnancy in North Shewa public hospitals, October 2022 (n � 650).

Table 7 :
Model-2.Bivariate and multivariable logistic regression analyses of variables' signifcant association with self-medication practice on conventional medicine during pregnancy in North Shewa Zone public hospitals, October 2022 (n � 650).

Table 8 :
Model-3.Bivariate and multivariable logistic regression analyses of variables signifcant association with self-medication practice on herbal medicine during pregnancy in North Shewa Zone public hospitals, October 2022 (n � 650).